Portal de Periódicos da CAPES

Special Report

2016; Lippincott Williams & Wilkins; Volume: 38; Issue: 4 Linguagem: Inglês

10.1097/01.eem.0000482465.90282.4c

1552-3624

Gina Shaw,

FigureEmergency medicine ranks at or near the top of nearly every national survey on physician burnout, a dubious honor that is reported over and over, as it was in one recent study that found that more than 70 percent of emergency physicians reported experiencing burnout significantly more than most other medical specialties. (Mayo Clin Proc 2015;90[12]:1600.) Many reasons have been offered for why emergency physicians have become burned to an extra-crispy degree, but most experts seem to agree the unpredictability and exhaustion of shift work is the real culprit. Shift work and long hours, in fact, have been identified as primary reasons why emergency physicians leave the field. (Acad Emerg Med 1998;5[3]:234.) Working the night shift can damage everything from your relationship with your children and spouse — shift workers tend to have higher divorce rates — to your cardiac and gastrointestinal health. (Occup Environ Med 2001;58[1]:68.) But the punishing nature of the night shift in a demanding 24/7 specialty isn't just difficult on physicians and their families, it puts every patient at a greater risk for a worn-out physician's potentially devastating medical errors. Think about your most recent stint on nights, and how you felt around 4 a.m. Would you have wanted your spouse or your child to get emergency care from an emergency physician who felt the way you were feeling then? “The complex of fatigue, sleep deprivation, and sleep debt is a significant contributor to diagnostic error,” said Pat Croskerry, MD, PhD, a professor in emergency medicine at Dalhousie University in Halifax, Nova Scotia, Canada, and one of the world's foremost experts on diagnostic errors in emergency medicine. “It's been suggested that sleep deprivation is the equivalent of being legally intoxicated. When we did a survey of emergency physicians, we found about a 30 percent decrement in cognitive performance from being sleep deprived. So if your IQ is around 120, by about 6 a.m. after you've been up all night, it's down to about 90.” This cognitive decline can lead to errors in even routine, uncomplicated tasks that you've performed many times before. “I've been running a cardiac arrest and fell asleep doing it, just for a few seconds,” Dr. Croskerry said. But when it comes to complex diagnostic challenges, sleep deprivation takes an even greater toll. A study of Harvard interns found that they made 21 percent more serious medication errors, but nearly six times as many serious diagnostic errors when working long, fatiguing shifts. (N Engl J Med 2004;351[18]:1838.) “The Challenger, the Exxon Valdez, Three Mile Island, Chernobyl — all of these major catastrophes were tied in some way to worker fatigue,” said Haney Mallemat, MD, an assistant professor of emergency medicine at the University of Maryland Medical Center, who spoke on the dangers of shift work and sleep deprivation at the Social Media and Critical Care Conference in June 2015. Shifting the Shifts Shift work plays havoc with circadian rhythms, the finely tuned harmony of the body's day-and-night cycle. Dr. Croskerry said ED scheduling should minimize this impact by striving to preserve the anchor period, a period of about four hours, generally somewhere between about 1 and 6 a.m., when the body's drive to sleep is strongest and when a significant amount of sleep is needed to preserve the body's circadian rhythm. “In the course of a typical night shift, most ED physicians work right through that anchor period. If you can preserve some meaningful sleep during the anchor period, people may still be somewhat off their stride a bit and compromised somewhat by sleep disruption, but not nearly as significantly as when they stay up right through the anchor period and don't have any sleep,” he said. Fifteen years ago, the emergency department at Dr. Croskerry's hospital modified its standard eight-hour shift schedule (7-3, 3-11, 11-7) to something referred to as casino shifts, based, as you may guess, on the way casino managers run their scheduling. They never switched back. Physician A on a casino shift may work from 10 p.m. to 4 a.m., and then go home to begin his sleep in the later part of his “anchor period.” Physician B would go to bed early in the evening, sleep until about 3 a.m. — getting some sleep during the early part of her anchor period — and then start her shift at 4 a.m. “You have to shift the anchor period back on some people and forward for others. Surveys show that people tend to organize themselves into either owls or larks, and ideally you can combine casino shifts with shift selection, letting people organize themselves into the circadian rhythm they're naturally inclined to follow. The owls would work the 10 p.m. to 4 a.m. casino shift, and the larks would work the 4 a.m. to 10 a.m. shift,” Dr. Croskerry said. His team found a significant increase in physician satisfaction and self-reported cognitive performance after the switch to the casino shift schedule. More than 80 percent of the physicians preferred the casino shift, as did 60 percent of their families. That department still enjoys low turnover rates, which Dr. Croskerry said he attributes in part to a reluctance to move to a department where they would have to return to standard shift scheduling. Casino shift scheduling also follows the sun, which helps the body stay in a normal sleep pattern, according to Dr. Mallemat. If you drive home from a normal ED night shift at 7:30 a.m., the sun is up and telling your body that it's time to stay awake, not time to go to sleep. “But with the 10 p.m.-4 a.m. casino shift, you get home before the sun rises and it doesn't feel like a new day, so you can get to bed and sleep the whole morning,” he said. “For the person who's going to work at 4 a.m., they rise as it's getting close to dawn, and the sun is still up when they get out of work, so they can go home, be with their family and go to bed a little earlier than normal.” Another approach to night-shift scheduling has recently been studied in a chemical plant in Germany. Called a “fast-forward rotating schedule,” it involves 12-hour shifts with transition times at 6 a.m. and 6 p.m. so a “day shift” and a “night shift.” It sounds exhausting, but the unique factor is that each 12-hour shift is followed by a minimum of 24 hours off. (Chronobiol Int 2016;33[1]:98; http://bit.ly/1PrzAAG.) “This means that employees have a full night sleep episode after each work shift, where they can compensate for their work-related sleep loss,” said lead author Dorothee Fischer, PhD, a postdoctoral research fellow at the Harvard T.H. Chan School of Public Health and the Liberty Mutual Research Institute for Safety in Boston. “For instance, employees start with the day shift at 6 a.m. on Monday and return home at 6 p.m. the same day. They go back to work the next day (Tuesday) at 6 p.m., allowing them to have a full night's sleep between the day shift and the night shift. After the night shift ends at 6 a.m. on Wednesday, they sleep during the day (on average between 6:30 a.m. and noon). Thursday is a day off, and they return to work on Friday at 6 a.m. for the dayshift, meaning they have 48 hours off between night shift and day shift and thus have a full night's sleep from Wednesday evening to Thursday morning.” Dr. Fischer's group found this new schedule reduced chronic sleep debt among the participants. “Most workers reported benefitting from the extra 24 hours off after the night shift,” she said. Of course, this type of schedule has not yet been tested in a hospital setting, but Dr. Fischer said she thinks it could be feasible. “Our and others' research suggests that it is not so much the weekly working hours that are critical for sleep and safety, but the composition of a work schedule. A schedule incorporating sufficiently long periods off work for recovery, thereby reducing build-up of sleep debt and preventing chronic fatigue, is certainly a way to address these concerns,” she said. Minimizing Fatigue Many emergency departments are still sticking with the standard shift schedule, however, Dr. Mallemat's among them. Other strategies can help compensate for the detrimental effects of circadian rhythm disruption and sleep debt in these situations. “First, we always have double coverage: at least two physicians on duty, even overnight. That allows for shared decision-making and reduces patient load, recognizing that people working the night shift may be limited in cognitive and procedural skills. We also allow self-selection to the degree we can, and have a couple of people who like overnight shifts. As a reward, they get a couple of shifts knocked off their full-time expectation as a thank you,” he said. When physicians change shifts, those should always rotate forward — never backward. The physician covering the 11 p.m.-7 a.m. shift should move to the 7 a.m.-3 p.m. shift, not backward to the 3 p.m.-11 p.m. slot. Dr. Mallemat said he also suggests that EDs should be lit brightly no matter the time. “Sometimes on overnight shifts there is a tendency to lower lights and try to make things quiet and peaceful. This dimming of the lights is typically in other parts of the hospital. But the ED knows no hours. You need the same level of intensity of care no matter what time it is, so you should have big bright lights on and keep the noise level normal,” he said. What about short naps? Those are difficult in the ED; a sudden wake-up just as you have dropped off may leave you jarred, groggy, and even more impaired than you were before. Instead, Dr. Mallemat suggested taking brief exercise breaks. “If you find yourself with a few minutes between patients, do some push-ups or jumping jacks and get your heart rate up. You'll be more alert.” Clinicians also need to stop “sucking it up” and taking the “quien es mas macho” approach to the night shift, he said. “On the days when we know we have a night shift, a lot of us are running around during the day doing our thing — taking the kids to school, paying bills, not cognizant of our fatigue. Then we take a little nap, but we don't get the sleep we need. We have to use strategies to fix some of this ourselves.” Dr. Mallemat recommended a few key sleep hygiene tips for night shift workers: Wear dark sunglasses on the way home from work to minimize your exposure to those “wake up!” messages from sunlight. Go straight home to bed after work. Don't stop to run errands or get busy with something else. Avoid caffeine and heavy foods as you are coming off shift; they will keep you up. Use eye masks, blackout shades, earplugs, and white noise machines to keep your bedroom dark and peaceful when you have to sleep in the morning. “We need to do more research into night shifts and sleep disruption as a profession,” Dr. Mallemat said. “And hospitals need to be aware that this is not just a comfort issue but an issue of physician health and patient safety.” Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].